A harbour where a fisherman fell to his death was “chaotic” and it was “inevitable” that an accident would occur, a report has concluded.

Jamie Barbeary, 37, died three years ago when he tried to cross from the quayside at Ilfracombe in north Devon to his vessel, the Olivia Belle, which was moored in the harbour.

An inquest jury this week recorded a verdict of accidental death after hearing the father-of-two was nearly three times the legal drink-drive limit when he attempted to cross the 3ft gap to his boat.

The jury said alcohol and the size of the gap were both factors in Mr Barbeary’s death, after hearing evidence from the Health and Safety Executive (HSE) that there were a number of tripping hazards nearby.

But an independent report commissioned by the HSE has raised concerns about the harbour.

Master mariner Christopher Spencer’s report was not admitted as evidence to the inquest, with HSE inspector Joanna Fitzgerald instead appearing before the jury.

However in his report, Mr Spencer wrote: “In my view this accident was inevitable (at some time) given the chaotic layout of the Cove area (of the harbour) and the lack of a proper means of access to the fishing vessels.”

It adds: “I am also of the view that there were many contributors to this accident as noted within the report. Not least poor guidance by the MCA, poor harbour layout by the harbour authorities, poor oversight by the owners and poor risk assessment by the skippers and crews.”

Mr Barbeary’s partner and mother of his two daughters, Jo Lucas, said: “I feel this independent assessment would have been crucial to forming a view of exactly what happened to Jamie.

“It has taken three years to get to the inquest stage, and we feel there are still many unanswered questions.”

The inquest heard Mr Barbeary’s vessel was due to fish in the Bristol Channel on October 11, 2009 but it delayed its journey due to concerns about the weather.

Mr Barbeary, who was born in north Devon and lived with his partner and children in St Thomas in Swansea, left the Olivia Belle at the harbour’s fuelling berth to head out on the next tide, shortly after midnight the following day. He was seen at a local pub from 2.30pm to 7.30pm, but never made it back to the boat.

A crew member resting below deck said he heard a bang on the boat that evening and went to investigate, but dismissed it after he could not see anything untoward.

Mr Barbeary’s body was found on the low tide the following morning. It was suggested he had fallen 20ft into the shallows, hitting his head on the concrete plinth below the fuelling berth.

Mr Spencer’s report said there was “little that could be done to protect those who are careless, have taken drink or drugs or are tired”, but added that the “features currently in use (at the harbour) are well below what could be described as best practice and do not preclude a wide awake, fit, sober person having an accident in similar fashion by simply tripping or making a mistake”.

He said the low frequency of incidents at the harbour was “no reason to ignore” any hazards or their possible consequences.

In a statement, Mike Mansell, chief executive of North Devon Council which owns and runs the port, said: “This was a tragic incident involving a very well-known and popular member of our community. Our thoughts are with Mr Barbeary’s friends and family and we hope that this outcome can bring some level of closure to what must have been a very difficult time for everyone concerned.”